East Java Governor Khofifah Indar Parawansa looks on as a woman is vaccinated. Photo by Antara/Humas Pemprov Jatim.
Indonesia is facing an ongoing rise in the number of Covid-19 cases, often described as a “never-ending” first wave. This is probably the result of ongoing geographic spread, with cases now increasing in most provinces. Meanwhile, the increasing number of people developing serious conditions is putting strain on hospital capacity. Shortages of ICU beds are being reported from areas with high numbers of cases.
The national update on 7 February reported nearly 80,000 new cases in the previous week, with increases in 26 of 34 provinces. Reported deaths reached 1,558 in the previous week, with the highest numbers recorded in the provinces of Java and Jakarta. Experts suspect the real number of deaths is even higher.
Testing has been increasing, to a daily average of 35,000 in January, but positivity rates remain high and reached an average of 26.5% in January, suggesting widespread community transmission.
The Indonesian government has been criticised for prioritising the economy ahead of public health, and viewing the pandemic through a public security lens. But it has moved quickly to set up a vaccination program, and has already begun rolling out the first vaccine, Sinovac’s CoronaVac.
The first phases of the vaccination program will target health workers and public servants, and then move on to the working age population (18-59). The government has faced criticism for delaying vaccination of the elderly, but stated that this was because the vaccine had only been approved for those aged 18-59 years. However, this targeting seems consistent with the government’s focus on the economy, by seeking to protect the workforce, rather than those at greatest risk of disease and death.
Vaccination programs can address two objectives: (a) protect those at greatest risk of infection and serious complications or death; and (b) increase the proportion of individuals in the population who are not susceptible to the infection, interrupting transmission of infection and thus reducing spread. The balance between these two objectives is critical.
The decision to commence vaccination with frontline workers and health care workers is consistent with protecting those at greatest risk, but the exclusion of those aged over 59 years, while consistent with the initial evidence on the Sinovac vaccine, means that a significant proportion of those at greatest risk of complications and death may not be protected. There are reports this week that the National Agency of Drug and Food Control (BPOM) has now approved the use of the vaccine in the elderly, and the minister of health said that vaccination of those over 60 years would begin on 8 February, with a focus on health care workers.
The current screening process for vaccine candidates before vaccination with Sinovac excludes people with many chronic conditions, such as autoimmune disorders, cardiovascular diseases and chronic renal disease, conditions that may increase the probability of severe Covid-19 presentation and higher mortality. It is not clear whether these exclusions will also be applied to those aged 60 years and over, who may have many of the excluded conditions. Neither is it clear if other vaccines that Indonesia has started to procure, such as the AstraZeneca and Pfizer vaccines, will be provided to individuals with existing chronic conditions.
There is also the question of the impact of vaccination on individuals who may be incubating the infection. Such individuals were excluded from the trials of the Sinovac vaccine. Covid-19 testing before vaccination is not required but the current pre-vaccination screening excludes those likely to be incubating infection, such as household contacts of cases, or with low grade symptoms.
Trials of the Sinovac vaccine indicated that while it is 78% protective against mild cases, it is 100% effective against moderate and severe cases. This would suggest that while the vaccine may provide protection against severe disease, it is less effective against mild disease, and thus may be less effective in preventing transmission. By excluding older people and those with chronic conditions that are more likely to suffer severe disease, the protective effect of the vaccination is not maximised. Meanwhile, its impact on spread in the population has yet to be demonstrated.
As we discussed in our previous blog, gaining public trust will be vital. Attempts to show public figures receiving vaccines and emphasising that the vaccine is halal demonstrate the government’s efforts to gain public trust in a country with a history of questioning vaccination. But keeping the public informed and supportive of the vaccination program will require a much greater effort.
For example, based on a survey conducted by the Indonesian Technical Advisory Group on Immunisation (ITAGI) in late 2020, 65% of the population indicated that they were willing to receive the vaccination. But 7.6% of respondents said they would refuse and the remaining 27.6% were undecided. The highest proportion of undecided responses came from the poor and vulnerable population (around 30-33%) compared to only 20% among the upper class. This implies that gaining public trust will continue to be a challenge and may require different strategies across population characteristics.
The multiple phases, different vaccines and target groups, not to mention the range of exclusions, will make this a complex and challenging exercise in communication with the public. There is a high risk of individuals complaining that they or their family members have been unfairly excluded, or have developed infection following vaccination, perhaps even accusations that vaccination has caused the infection. Further, the government has still not sufficiently clarified whether the focus of the program is to reduce severe disease or to reduce spread, or how these two aims are addressed in the current roll-out schedule.
There is also the question of the pace of vaccination, the geographic phasing and the time required to reach the whole population, which may result in accusations that the government is favouring or excluding certain areas or population groups.
By the end of the first week of February 2021, the vaccination rate ranged from 50,000 to 80,000 people per day, which is well below the official target of at least 900,000 to 1 million individuals vaccinated daily. It will take time to reach the optimum level, although this should eventually be feasible given the number of available qualified health personnel in primary and secondary level health facilities.
But even at 1 million doses per day, it would take at least 15 months to provide one dose to the 181.5 million population being targeted for vaccination, let alone a follow-up second dose. As immunity following vaccination is predicted to last only around 6 months, there could be possible reinfection among vaccinated individuals even before universal vaccination has been achieved.
While initial screening to exclude incubating or asymptomatic infection would be ideal, this may be logistically complex, as vaccination would need to be delayed while waiting for results. But in the absence of screening, there is the potential for vaccinated individuals to subsequently develop infection, and even disease, if they were incubating infection at the time of vaccination. This could bring the effectiveness of the vaccine into doubt in the public mind.
Particularly in the current context of low rates of testing and high levels of community transmission, the opportunity to test before vaccination (even without waiting for results before administering the vaccine) could also provide valuable information on the extent of spread in the community, and explain potential infections post vaccination.
WHO does not recommend screening for Covid-19 infection before vaccination for the Pfizer vaccine, where there is better evidence that vaccination of infected individuals is not harmful. But using vaccination as an opportunity to test at a population level would not need to result in any delay in the vaccination process, and could confer huge benefits.
Greater transparency on the aims of the vaccination program and on the exclusions and potential for illness in incubating individuals might reassure the public. Meanwhile, adding screening for infection before vaccination could provide valuable data on the extent of spread in the population, and could be used to monitor the effectiveness of the program.
Indonesia has made some important first steps toward vaccinating its population against Covid-19. But it still has a long and convoluted journey ahead of it.
